Patient Information & Medical History Nurse/Doctor appointment

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Blake Ray
5 years ago
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18 William Street Bellingen NSW 2454 Phone: 6655 0000 Fax: 6655 0266 ABN 35 616 896 074 bhc@bellingenhealingcentre.com.

1 18 William Street Bellingen NSW 2454 Phone: Fax: ABN Patient Information & Medical History Nurse/Doctor appointment Name of patient: Mr Mrs Ms Miss First Name Surname Current Address: Date of Birth: / / Gender: Male Female Phone Details: Home: Work: Mobile: Medicare Card Number: Ref Number: Expiry Date: / Pension Card: Expiry Date: / / Health Care Card: Expiry Date: / / DVA Card: DVA Colour: White Gold Orange Indigenous Status: N/A Aboriginal Torres Strait Islander: Registered For Closing The Gap: Y N Country of Birth: Primary Language: Occupation: Next of Kin/Emergency Contact Name: Alternate Phone: Occupation: DOB: Relationship to you: Bellingen Healing Centre promotes a policy of ZERO TOLERANCE toward workplace violence, including but not limited to: physical assault, threatening behaviour, obscene phone calls or verbal abuse. If you are unable to do this then we have no alternative other than to cease our clinical service to you. A full copy of this policy can be provided upon request. I understand and agree to abide by the above policy and that non-compliance may result in the cessation of care at this practice. Signed: Date: Signed as Guardian of child: Date: Guardian s Name (printed): DOB:

2 MEDICAL HISTORY Have you or your child ever had any of the following: Operations: Asthma: Diabetes: Hypertension: Chronic illness: Known Allergies: Other Health Conditions: CURRENT MEDICATIONS FAMILY HISTORY: Please provide a short family health history of the following family members who may have Diabetes Asthma Heart Disease Cancer Mental Illness: Please outline any mental health issues in your family e.g. anxiety, depression, bi-polar, schizophrenia etc. Father Mother Siblings Your Children Grandparents Aunts,Uncles,Cousins Children s Immunisations If completing this form for a child, are their immunisations up to date? Childs current medications (including over the counter medications, vitamins and minerals):

3 Social history: I have never smoked Ceased Smoking / / : Currently Smoke per day I do not drink alcohol drinks per day /week/month If more than 6 drinks per day, how often? Recreational drug use: (type and frequency) Height if known: cms Weight if known: kgs Waist Measurement if known: cms Blood Pressure if known: / last time your blood pressure was taken? / / How often do you exercise or engage in physical activity for 30 minutes or more? Daily times per Week never other: Females - When did you last have a: Pap smear Date: Not Sure Never Breast Check Date: Not Sure Never Mammogram Date: Not Sure Never Males - When did you last have an overall check up Date: Not Sure Never For those 65 years and older: When was the last time you were immunised for Influenza (Flu Shot) Date: Not Sure Never Pneumococcal Pneumonia Date: Not Sure Never Is there any other information that you believe we should know that may affect / or have an influence on the medical treatment / advice you or your child will be provided with? If yes, please provide details below - Signature (adult):... Date: Signed as Guardian of Child:.. Guardian s Name (printed):.. DOB

4 Collection of Personal Information, Privacy Act 1988 (Cth) and HRIP Act 2002 (NSW) Bellingen Healing Centre collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assist, diagnose and treat illnesses and be pro-active in your health care. We will also use the information you provide in the following ways: Administrative purposes in running our medical practice Billing purposes, including compliance with Medicare and Health Insurance Commission requirements Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice Disclosure for research and quality assurance activities to improve individual and community health care as well as practice management. You will be informed when such activities are being conducted and given the opportunity to opt-out of any involvement. I have read the information above and understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am also aware that this practice has a privacy policy which contains information about accessing and seeking correction of personal information, as well as the privacy complaints handling process. I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. I understand that if I request access to information about me, the practice will be entitled to charge fees to cover time and administrative costs which may not be covered by a Medicare rebate. I understand that if my information is to be used for any purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of. Signed: Signed as Guardian for child:.. Guardian s Name: (printed) Guardian s DOB:

5 18 William Street Bellingen NSW 2454 Phone: Fax: ABN Consent/Request for Health Records and Information Changes to the Privacy Laws now means that a person or guardian s written consent is required for health professionals to request and obtain medical information concerning that person or to communicate medical information about that person to other practitioners. For Bellingen Healing Centre to request medical information required for your ongoing care and to liaise with other practitioners we need you to sign this form. I, DOB Medicare Number Hereby give my permission for the doctors at Bellingen Healing Centre to 1. Obtain medical information about previous consultations, results of investigations and details of past treatment from government departments, other medical practitioners, hospitals and health care providers that relates to my medical condition. 2. Communicate with medical practitioners, hospitals, health care providers and other health professionals concerning my medical condition. Patient s name: Patient s signature (adult):.. Date: Signed as Guardian for child: Guardian s Name: (printed) Guardian s DOB: Bellingen Healing Centre will use this consent on an ongoing basis to collect information relevant to your health care. If you wish at any stage to withdraw your consent please inform us of your decision in writing. Kind Regard, Bellingen Healing Centre Practice Request for Patient Records To: Previous Dr Practice Fax: Address: The above named patient/s are now attending Bellingen Healing Centre for ongoing health care; please supply patient health information IN PDF (we are unable to read XML) in the follow specific format: Accurate summary Full copy of Health Information Please provide copy of current plan Date of last: 721 MHP

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email